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BRIOVARX OF MASSACHUSETTS, LLC
DSH330241 UNIVERSITY HOSPITAL
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Covered Entity Details
Entity Name
UNIVERSITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330241
Entity Address
750 East Adams Street
Syracuse, NY 13210
Medicare Provider Number
330241
Participating Start Date
7/1/2005
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
BRIOVARX OF MASSACHUSETTS, LLC
Pharmacy Address
D/B/A BRIOVARX
BLDG 2 - UNIT A
145 BODWELL STREET
AVON, MA 02322
Pharmacy Comments
Contract Details
Approval Date
1/17/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2019
Pharmacy closed
Contacts
Covered Entity Signing Official
Robert John Corona, CEO
(315) 464-4223
Contract Pharmacy Representative
Optum RX
Joseph Iovino, VP
(412) 445-4495
Signed By Date
1/17/2019
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